Kit, composition, and combination therapy for fragile x syndrome

ABSTRACT

Described herein are kits, compositions, and combination therapies comprising sulindac for use in the treatment of fragile X syndrome (FXS).

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.16/383,037, filed on Apr. 12, 2019, which claims the benefit of U.S.Provisional Application No. 62/657,275, filed on Apr. 13, 2018. Theentire teachings of the above applications are incorporated herein byreference.

FIELD OF THE INVENTION

This invention relates to a kit, composition and combination therapycomprising sulindac for use in the treatment of fragile X syndrome(FXS).

BACKGROUND OF THE INVENTION

Fragile X syndrome, often referred to as fragile X, is the most commoninherited cause of intellectual impairment and the most common monogeniccause of autism. It affects around 1 in 4000 males and 1 in 6000 femalesworldwide. There are a wide range of characteristics associated withfragile X, and typically males are more affected than females. One ofthe major characteristics associated with fragile x syndrome isintellectual impairment, such as difficulties with cognitive, executiveand language performance. Individuals with fragile x syndrome typicallyhave social anxiety characterised by social, emotional and communicationdifficulties related to extreme shyness, poor eye contact and challengesforming peer relationships. Fragile x syndrome is also associated withhyperactivity and disruptive behaviour, such as short attention span,distractibility, impulsiveness, restlessness, over-activity and sensoryproblems. Furthermore, individuals with fragile x syndrome often sufferfrom seizures.

Fragile x syndrome arises from a mutation in a single gene calledFragile X Mental Retardation Gene 1 (FMR1). The 5′ UTR of FMR1 containsa CGG trinucleotide repeat that is polymorphic in the population. Oncethe repeats exceed 200 in number, methylation of the promoter istriggered, and this in turn causes the lack of expression of the geneand translation of its encoded protein, the Fragile X Mental RetardationProtein (FMRP). FMRP is an RNA-binding protein involved in differentsteps of mRNA metabolism, such as translational control (in soma anddendritic spines) and RNA transport.

At present, there is no effective therapy to treat fragile x syndrome.However, there have been considerable efforts to identifypharmacological targets to treat this disorder. In particular, fragile xsyndrome has been a frequent target of repurposing efforts as well asrepositioning of drugs in development. Many different standards andmethods have been applied to this task. In many cases, repurposingcandidates have been identified based primarily on clinical patternmatching, while in others basic disease mechanisms have been studiedextensively to identify therapeutic targets, followed by thoroughpreclinical validation.

Efforts to treat fragile x syndrome have included investigations into;lithium, minocycline, lovastatin, metformin, and EGCG (green teaextract), inter alia. Overall, efforts to treat fragile x syndrome haveled to some exciting possibilities, but no definitive successes, despitemuch effort. This has highlighted the need for new therapies.

Sulindac is a non-steroidal anti-inflammatory drug (NSAID). Sulindac isused in the treatment of acute and chronic inflammatory conditions, suchas arthritis, shoulder bursitis and tendonitis, as it exhibitsanti-inflammatory, analgesic and antipyretic activities. Like otherNSAIDs, the mechanism of action of sulindac is not fully understood.However, it is thought to be related to prostaglandin synthetaseinhibition.

Sulindac is a yellow crystalline compound, and is a weak organic acidpractically insoluble in water below pH 4.5, but very soluble as thesodium salt or in buffers of pH 6 or higher. Following absorption,sulindac undergoes two major biotransformations (i) reversible reductionto the active sulfide metabolite, and (ii) irreversible oxidation to theinactive sulfone metabolite. Sulindac has the systematic name(Z)-5-fluoro-2-methyl-1-[[p-(methylsulfinyl)phenyl]methylene]-1H-indene-3-aceticacid.

Sulindac is marketed as CLINORIL®, in 200 mg tablets for oraladministration. The tablets contain sulindac, cellulose, magnesiumstearate, and starch. CLINORIL® is used to treat osteoarthritis,rheumatoid arthritis, ankylosing spondylitis, acute subacromialbursitis/supraspinatus tendinitis and acute gouty arthritis. A typicaldosage is 150 mg to 200 mg twice per day.

SUMMARY OF THE INVENTION

The present invention is based on in vivo and in silico data. The belowlisted compounds have been identified as being useful in the treatmentof fragile x syndrome, when used in combination with sulindac. This isbased on the below in vivo data, along with in silico data obtained withproprietary algorithms which indicated the compounds listed as CompoundA will provide a synergistic combination with sulindac in the treatmentof fragile x syndrome.

In a first aspect of the invention, there is provided a kit for useaccording to claim 1.

In a second aspect of the invention, there is provided a kit accordingto claim 18.

In a third aspect of the invention, there is provided a composition foruse according to claim 20.

In a fourth aspect of the invention, there is provided a compositionaccording to claim 22.

In a fifth aspect of the invention, there is provided a method accordingto claim 24.

DESCRIPTION OF THE FIGURES

FIG. 1A show the results from sulindac in vivo testing.

FIG. 1B show the results from sulindac in vivo testing.

FIG. 1C show the results from sulindac in vivo testing.

FIG. 1D show the results from sulindac in vivo testing.

FIG. 2A show the results from metoprolol in vivo testing.

FIG. 2B show the results from metoprolol in vivo testing.

FIG. 2C show the results from metoprolol in vivo testing.

FIG. 2D show the results from metoprolol in vivo testing.

FIG. 3A show the results from sulindac and ibudilast in vivo testing.

FIG. 3B show the results from sulindac and ibudilast in vivo testing.

FIG. 3C show the results from sulindac and ibudilast in vivo testing.

FIG. 3D show the results from sulindac and ibudilast in vivo testing.

FIG. 4A show the results from sulindac and sertraline in vivo testing.

FIG. 4B show the results from sulindac and sertraline in vivo testing.

FIG. 4C show the results from sulindac and sertraline in vivo testing.

FIG. 4D show the results from sulindac and sertraline in vivo testing.

FIG. 5A show the results from sulindac and quercetin in vivo testing.

FIG. 5B show the results from sulindac and quercetin in vivo testing.

FIG. 5C show the results from sulindac and quercetin in vivo testing.

FIG. 5D show the results from sulindac and quercetin in vivo testing.

FIG. 5E show the results from sulindac and quercetin in vivo testing.

FIG. 6A show the results from sulindac and cannabidiol in vivo testing.

FIG. 6B show the results from sulindac and cannabidiol in vivo testing.

FIG. 6C show the results from sulindac and cannabidiol in vivo testing.

FIG. 6D show the results from sulindac and cannabidiol in vivo testing.

FIG. 7A show the results from sulindac and minocycline in vivo testing.

FIG. 7B show the results from sulindac and minocycline in vivo testing.

FIG. 7C show the results from sulindac and minocycline in vivo testing.

FIG. 7D show the results from sulindac and minocycline in vivo testing.

FIG. 8A show the results from sulindac and topiramate in vivo testing.

FIG. 8B show the results from sulindac and topiramate in vivo testing.

FIG. 8C show the results from sulindac and topiramate in vivo testing.

FIG. 8D show the results from sulindac and topiramate in vivo testing.

FIG. 8E show the results from sulindac and topiramate in vivo testing.

DETAILED DESCRIPTION

As fragile x is a syndrome, there are a number of differentmanifestations and symptoms in patients. These include; intellectualimpairment, such as difficulties with cognitive, executive and languageperformance, short-term memory, executive function, visual memory andvisual-spatial relationships; autism; social anxiety (i.e. difficultiesin social interaction) such as poor eye contact, gaze aversion,prolonged time to commence social interaction, and challenges formingpeer relationships; hyperactivity and repetitive behaviour, includingvery short attention spans, hypersensitivity to visual, auditory,tactile, and olafactory stimuli, distractibility, impulsiveness,restlessness and over-activity; disruptive behaviour, includingfluctuating mood, irritability, self-injury and aggression; obsessivecompulsive disorder (OCD); ophthalmologic problems, such as strabismus;seizures; difficulties with working memory, which involves the temporarystorage of information while processing the same or other information;difficulties with phonological memory (or verbal working memory); andfragile X-related primary ovarian insufficiency (FXPOI).

In the present invention, a kit or a composition comprising sulindac andCompound A is used to treat one or more of the above symptoms, and istherefore an effective treatment of fragile x syndrome. Preferably, thekit or composition according to the present invention is used fortreatment of fragile x syndrome when the patient is exhibiting typicalsymptoms of the syndrome including social anxiety, hyperactivity, memoryloss and/or disruptive behaviour. More preferably, the kit orcomposition according to the present invention is used for the treatmentof fragile x syndrome, wherein the patient is exhibiting hyperactivity,memory loss and/or disruptive behaviour.

The term “hyperactivity” has its normal meaning in the art.Hyperactivity may include having very short attention spans,hypersensitivity to visual, auditory, tactile, and olafactory stimuli,distractibility, impulsiveness, restlessness and/or over-activity.

The term “social anxiety” has its normal meaning in the art. It may alsobe termed as difficulties in social interaction or low sociability.Social anxiety may include having poor eye contact, gaze aversion,prolonged time to commence social interaction, social avoidance orwithdrawal and challenges forming peer relationships.

The term “memory loss” has its normal meaning in the art. It refers toan inability to retain information either short-term or long-term. Itmay also be called memory impairment. It may include difficulties withcognitive, executive and language performance, executive function andvisual memory. It may also include difficulties with working memory,also called short-term memory (i.e. the temporary storage of informationwhile processing the same or other information) and difficulties withphonological memory (or verbal working memory).

The term “disruptive behaviour” has its normal meaning in the art. Itmay also include repetitive behaviour. It may also include fluctuatingmood, irritability, self-injury and aggression.

It is known that sulindac undergoes two major biotransformationsfollowing absorption (i) reversible reduction to the sulphidemetabolite, and (ii) irreversible oxidation to the sulfone metabolite.However, the mechanism by which sulindac treats fragile x syndrome isnot yet known. Therefore, for the avoidance of doubt, any reference tosulindac also embraces its metabolites (both the sulphide and sulfonemetabolites).

In the present invention, for the kits or compositions according to theinvention, Compound A is selected from the following list: minocycline,doxycycline, lovastatin, metformin, epigallo catechin gallate(EGCG—green tea extract), lithium, sertraline, tideglusib, lamotrigine,acamprosate, ganaxolone, basimglurant, mavoglurant, methylphenidate,L-carnitine, L-acetyl carnitine, zardaverine, ibudilast, metoprolol,penbutolol, fasudil, carbamazepine, midostaurin, sildenafil, tadalafil,gabapentin, stiripentol, donepezil, tetracyclines, cannabidiol,curcumin, simvastatin, atorvastatin, pravastatin, fluvastatin,rosuvastatin, pitavastatin, apigenin, telmisartan, medium and long chainfatty acids, indirubin, pregabalin, baclofen, arbaclofen, memantine,ethchlorvynol, fenobam, riluzole, crisaborole, S-rolipram, apremilast,cilomilast, roflumilast, dipyridamole, drotaverine, propentofylline,caffeine, papaverine, trapidil, flavoxate, amlexano X, pentoxifylline,propanolol, pindolol, acebutalol, bisoprolol, carvedilol, labetalol,metipranolol, oxprenalol, pindolol, tertatolol, timolol, topirimate,tianeptine, quercetin, disulfiram, imatinib, gefitinib, selumetinib,refametinib, fusidic acid, lorazepam, phenobarbital, vardenafil,udenafil, avanafil, ruxolitinib, momelotinib, bortezomib, carfilzomib,carnosol, riluzole, luteolin, carnosic acid, resveratrol,methylphenidate, menadione, taurine, niacin, clorazepic acid, diazepamand other ‘azepam’ class drugs, chlordiazepoxide, staurosporin,gaboxadol, progabide, tulrampator, ketamine, decanoic acid, piracetam,pramiracetam, dexmethylphenidate, oglemilast, levetiracetam andvigabatrin.

In a preferred embodiment, for the kits or compositions according to thepresent invention, Compound A is selected from the following list:minocycline, doxycycline, lovastatin, metformin, epigallo catechingallate (EGCG—green tea extract), quercetin, lithium, sertraline,topiramate, cannabidiol, tideglusib, lamotrigine, acamprosate,ganaxolone, basimglurant, mavoglurant, methylphenidate, L-carnitine,L-acetyl carnitine, zardaverine, ibudilast, metoprolol, penbutolol,fasudil, carbamazepine, midostaurin, gabapentin, stiripentol, fenobam,and donepezil.

More preferably, Compound A is selected from minocycline, doxycycline,lovastatin, metformin, quercetin, lithium, sertraline, topiramate,cannabidiol, zardaverine, ibudilast, fasudil, midostaurin, fenobam,metoprolol and donepezil. More preferably, it is selected fromibudilast, sertraline, quercetin, cannabidiol, minocycline, topiramateand metoprolol.

Most preferably, Compound A is selected from ibudilast, sertraline,quercetin, cannabidiol, minocycline and topiramate.

Minocycline is a tetracycline antibiotic which is commonly used in thetreatment of acne vulgaris.

Doxycycline is a synthetic, broad-spectrum tetracycline antibioticexhibiting antimicrobial activity. It is commonly used in the treatmentof bacterial pneumonia and acne vulgaris.

Lovastatin is a cholesterol lowering agent isolated from a strain ofAspergillus terreus.

Metformin is a biguanide hypoglycemic agent used in the treatment ofnon-insulin-dependent diabetes mellitus.

Epigallo catechin gallate (EGCG), also known asepigallocatechin-3-gallate, is the ester of epigallocatechin and gallicacid and is a type of catechin. It is found in high content in greentea.

Sertraline is a selective serotonin re-uptake inhibitor (SSRI) used inthe treatment of major depressive disorder.

Lithium medication is commonly used in the treatment of psychiatricdisorders.

Quercetin is a plant flavanol found in many fruits, vegetables, andgrains. It is used in dietary supplements, beverages and foods. It hasanti-oxidant activity and is also known to have non-specific proteinkinase enzyme inhibiting properties and other pleiotropic actions.

Topiramate is a sulfamate modified fructose diacetonide used in thetreatment of epilepsy.

Cannabidiol is a phytocannabinoid.

Tideglusib is a small molecule non-ATP-competitive glycogen synthasekinase 3 (GSK-3) inhibitor. It is currently being investigated forpossible uses in Alzheimer's disease.

Lamotrigine is a synthetic phenyltriazine which is used as anantiseizure medication. It is commonly used to treat epilepsy andbipolar disorder.

Acamprosate is a synthetic amino acid and a neurotransmitter analoguethat is used in management of alcohol dependence and abuse.

Ganaxolone is the 3β-methylated synthetic analog of allopregnanolone; itbelongs to a class of compounds referred to as neurosteroids. It iscurrently being investigated for the treatment of epilepsy.

Basimglurant is a mGlu5 negative allosteric modulator currently beinginvestigated for treatment of depression and major depressive disorder.

Mavoglurant is a mGluR5 antagonist.

Methylphenidate is a central nervous system (CNS) stimulant. It iscommonly used for the therapy of attention deficit disorder andnarcolepsy.

L-carnitine, also called levocarnitine, is an amino acid derivative. Itis commonly used to treat carnitine deficiency. L-acetyl carnitine is anacetylated form of L-carnitine.

Zardaverine is a phospho-diesterase 4 inhibitor.

Ibudilast is an anti-inflammatory and neuroprotective agent. It iscommonly used in the treatment of asthma and stroke.

Metoprolol is a selective adrenergic beta-1 blocking agent that iscommonly used to treat hypertension, angina pectoris and myocardialinfarction.

Penbutolol is a nonselective beta-blocker used as an antihypertensiveand an antianginal agent.

Fasudil is a Rho kinase inhibitor and vasodilator. It is used to treatcerebral vasospasm.

Carbamazepine is a tricyclic compound which is an anticonvulsant drug.It is commonly used to treat seizures.

Midostaurin is a synthetic indolocarbazole multikinase inhibitor. It isused in the treatment of acute myeloid leukemia and systemicmastocytosis.

Gabapentin is a anticonvulsant that is used in the treatment of epilepsyand neuropathic pain syndromes.

Stiripentol is an anticonvulsant drug used in the treatment of epilepsy.

Fenobam is imidazole derivative.

Donepezil is an oral acetylcholinesterase inhibitor used for therapy ofAlzheimer's disease.

In a preferred embodiment, for the kits or compositions according to thepresent invention, Compound A is selected from the following list:minocycline, doxycycline, lovastatin, metformin, epigallo catechingallate (EGCG—green tea extract), lithium, tideglusib, lamotrigine,acamprosate, ganaxolone, basimglurant, mavoglurant, methylphenidate,L-carnitine, L-acetyl carnitine, tetracyclines, cannabidiol, curcumin,simvastatin, atorvastatin, pravastatin, fluvastatin, rosuvastatin,pitavastatin, apigenin, telmisartan, medium and long chain fatty acids,indirubin, pregabalin, baclofen, arbaclofen, memantine, ethchlorvynol,fenobam, riluzole, gaboxadol, progabide, tulrampator, ketamine, decanoicacid, piracetam, pramiracetam and dexmethylphenidate. Most preferably,it is selected from minocycline, doxycycline, lovastatin, metformin,epigallo catechin gallate (EGCG-green tea extract), lithium, tideglusib,lamotrigine, acamprosate, ganaxolone, basimglurant, mavoglurant,methylphenidate, L-carnitine, L-acetyl carnitine. The above compoundsare known from off-label use or clinical trials for treatment ofsymptoms fragile x syndrome. These drugs have been identified as showingsynergistic effects in the treatment of fragile x syndrome, when used incombination with sulindac, based on in silico data generated fromproprietary algorithms.

In a preferred embodiment, for the kits or compositions according to thepresent invention, Compound A is selected from the following list:zardaverine, ibudilast, metoprolol, penbutolol, fasudil, crisaborole,S-rolipram, apremilast, cilomilast, roflumilast, dipyridamole,drotaverine, propentofylline, caffeine, papaverine, trapidil, flavoxate,amlexano X, pentoxifylline, propanolol, pindolol, acebutalol,bisoprolol, carvedilol, labetalol, metipranolol, oxprenalol, pindolol,tertatolol, timolol, topirimate, tianeptine, quercetin, disulfiram,imatinib, gefitinib, selumetinib, refametinib, oglemilast and fusidicacid. Most preferably, it is selected from zardaverine, ibudilast,metoprolol, penbutolol and fasudil. These compounds have been identifiedas showing synergistic effects in the treatment of fragile x syndrome,when used in combination with sulindac, based on in silico data.

In a preferred embodiment, for the kits or compositions according to thepresent invention, Compound A is selected from the following list:carbamazepine, carnosol, riluzole, luteolin, carnosic acid, resveratrol,methylphenidate, menadione, taurine, niacin, clorazepic acid,chlordiazepoxide, diazepam and other ‘azepam’ class drugs. Mostpreferably, it is carbamazepine. These compounds have been identified asshowing synergistic effects in the treatment of fragile x syndrome, whenused in combination with sulindac, based on in silico data.

In a preferred embodiment, for the kits or compositions according to thepresent invention, Compound A is selected from midostaurin, ruxolitinib,momelotinib, bortezomib and carfilzomib; most preferably, midostaurin.These compounds have been identified in clinical trials for treatment offragile x syndrome, but have not yet been approved. They have also beenidentified as showing synergistic effects in the treatment of fragile xsyndrome, when used in combination with sulindac, based on in silicodata.

In a preferred embodiment, for the kits or compositions according to thepresent invention, Compound A is selected from sildenafil, tadalafil,vardenafil, udenafil and avanafil; most preferably sildenafil andtadalafil. These compounds act through similar mechanisms to sulindac.They have also been identified as showing synergistic effects in thetreatment of fragile x syndrome, when used in combination with sulindac,based on in silico data.

In a preferred embodiment, for the kits or compositions according to thepresent invention, Compound A is selected from gabapentin, stiripentol,ganaxolone, cannabidiol, lorazepam, phenobarbital, levetiracetam andvigabatrin; most preferably gabapentin, stiripentol and ganaxolone.These drugs are known to have anti-epileptic actions. They have alsobeen identified as showing synergistic effects in the treatment offragile x syndrome, when used in combination with sulindac, based on insilico data.

In a preferred embodiment, for the kits or compositions according to thepresent invention, Compound A is selected from fenobam, staurosporin,midostaurin, taurine, luteolin, memantine and donepezil. These drugs areknown to treat memory impairment. They have also been identified asshowing synergistic effects in the treatment of fragile x syndrome, whenused in combination with sulindac, based on in silico data.

As used herein, a pharmaceutically acceptable salt is a salt with apharmaceutically acceptable acid or base. Pharmaceutically acceptableacids include both inorganic acids such as hydrochloric, sulphuric,phosphoric, diphosphoric, hydrobromic or nitric acid and organic acidssuch as citric, fumaric, maleic, malic, ascorbic, succinic, tartaric,benzoic, acetic, methanesulfonic, ethanesulfonic, salicylic, stearic,benzenesulfonic or p-toluenesulfonic acid. Pharmaceutically acceptablebases include alkali metal (e.g. sodium or potassium) and alkali earthmetal (e.g. calcium or magnesium) hydroxides and organic bases such asalkyl amines, aryl amines or heterocyclic amines.

The kits or compositions according to the present invention may beadministered in a variety of dosage forms. In one embodiment, it may beformulated in a format suitable for oral, rectal, parenteral, intranasalor transdermal administration or administration by inhalation or bysuppository.

The kits or compositions according to the present invention may beadministered orally, for example as tablets, troches, lozenges, aqueousor oily suspensions, dispersible powders or granules. Preferably, thekits or compositions are formulated such that they are suitable for oraladministration, for example tablets and capsules.

The kits or compositions according to the present invention may also beadministered parenterally, whether subcutaneously, intravenously,intramuscularly, intrasternally, transdermally or by infusiontechniques. It may also be administered as suppositories.

The kits or compositions according to the present invention may also beadministered by inhalation. An advantage of inhaled medications is theirdirect delivery to the area of rich blood supply in comparison to manymedications taken by oral route. Thus, the absorption is very rapid asthe alveoli have an enormous surface area and rich blood supply andfirst pass metabolism is bypassed.

The present invention also provides an inhalation device containing thekits or compositions according to the present invention. Typically saiddevice is a metered dose inhaler (MDI), which contains apharmaceutically acceptable chemical propellant to push the medicationout of the inhaler.

The kits or compositions according to the present invention may also beadministered by intranasal administration. The nasal cavity's highlypermeable tissue is very receptive to medication and absorbs it quicklyand efficiently. Nasal drug delivery is less painful and invasive thaninjections, generating less anxiety among patients. By this methodabsorption is very rapid and first pass metabolism is usually bypassed,thus reducing inter-patient variability. Further, the present inventionalso provides an intranasal device containing the kits or compositionsaccording to the present invention.

The kits or compositions according to the present invention may also beadministered by transdermal administration. For topical delivery,transdermal and transmucosal patches, creams, ointments, jellies,solutions or suspensions may be employed. The present inventiontherefore also provides a transdermal patch containing the kits orcompositions according to the present invention.

The kits or compositions according to the present invention may also beadministered by sublingual administration. The present inventiontherefore also provides a sub-lingual tablet comprising the kits orcompositions according to the present invention.

The kits or compositions according to the present invention may also beformulated with an agent which reduces degradation of the substance byprocesses other than the normal metabolism of the patient, such asanti-bacterial agents, or inhibitors of protease enzymes which might bethe present in the patient or in commensural or parasite organismsliving on or within the patient, and which are capable of degrading thecompound.

Liquid dispersions for oral administration may be syrups, emulsions andsuspensions.

Suspensions and emulsions may contain as carrier, for example a naturalgum, agar, sodium alginate, pectin, methylcellulose,carboxymethylcellulose, or polyvinyl alcohol. The suspension orsolutions for intramuscular injections may contain, together with theactive compound, a pharmaceutically acceptable carrier, e.g. sterilewater, olive oil, ethyl oleate, glycols, e.g. propylene glycol, and ifdesired, a suitable amount of lidocaine hydrochloride.

Solutions for injection or infusion may contain as carrier, for example,sterile water or preferably they may be in the form of sterile, aqueous,isotonic saline solutions.

In an embodiment of the invention, the kits or compositions according tothe present invention are administered in an effective amount to treatthe symptoms of fragile x syndrome. An effective dose will be apparentto one skilled in the art, and is dependent on a number of factors suchas age, sex, weight, which the medical practitioner will be capable ofdetermining.

In a preferred embodiment, the at least one dose of sulindac comprises 5mg to 400 mg, more preferably 50 mg to 300 mg, most preferably 150 mg to200 mg. The lower limit for the at least one dose of sulindac ispreferably 5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 45 mg,50 mg, 55 mg, 60 mg, 65 mg, 70 mg, 75 mg, 80 mg, 85 mg, 90 mg, 95 mg,100 mg, 110 mg, 120 mg, 130 mg, 140 mg, 150 mg, 160 mg, 170 mg, 180 mg,190 mg or 200 mg. The upper limit for a dose is preferably 400 mg, 390mg, 380 mg, 370 mg, 360 mg, 350 mg, 340 mg, 330, mg, 320 mg, 310 mg, 300mg, 290 mg, 280 mg, 270 mg, 260 mg, 250 mg, 240 mg, 230 mg, 220 mg or210 mg. Any of the aforementioned lower or upper limits of the rangesmay be combined with each other, and are herein disclosed. Any of theabove doses may be administered once a day, twice a day, three times aday or four times a day.

In the kits or compositions according to the present invention, any ofthe aforementioned unit doses of sulindac may be combined with any ofthe aforementioned unit does of Compound A.

The kit according to the present invention provides for theadministration of more than one drug, and they can be administeredsimultaneous, sequentially or separately. It is not necessary that theyare packed together (but this is one embodiment of the invention). It isalso not necessary that they are administered at the same time. As usedherein, “separate” administration means that the drugs are administeredas part of the same overall dosage regimen (which could comprise anumber of days), but preferably on the same day. As used herein“simultaneously” means that the drugs are to be taken together orformulated as a single composition. As used herein, “sequentially” meansthat the drugs are administered at about the same time, and preferablywithin about 1 hour of each other. Preferably, the kit is administeredsimultaneously i.e. taken together or formulated as a singlecomposition. Most preferably, it is formulated as a single composition.

In an embodiment of the invention, the kit is administered at least oncea day. Preferably it is administered as a single daily dose. Preferablythe single daily dose is administered simultaneously i.e. sulindac andCompound A are taken together or formulated as a single composition. Inthis embodiment, most preferably, it is formulated as a singlecomposition. Preferably the single daily dose comprises of 200 mg to 400mg of sulindac, preferably 300 mg to 400 mg. Preferably it comprises 200mg, 250 mg, 300 mg, 350 mg or 400 mg of sulindac. It may also beadministered sequentially i.e. at about the same time, and preferablywithin about 1 hour of each other.

In an embodiment of the invention, the kit may be administered twicedaily. Preferably each daily dose is administered simultaneously i.e.sulindac and Compound A are taken together or formulated as a singlecomposition. In this embodiment, most preferably, it is formulated as asingle composition, which is administered twice daily. Preferably eachdose comprises 150 mg to 200 mg of sulindac, with a total daily dosageof sulindac of 300 mg to 400 mg. Most preferably, each daily dosecomprises 200 mg of sulindac, with a total daily dosage of sulindac of400 mg. Each daily dose may also be administered sequentially i.e.sulindac and Compound A are administered at about the same time, andpreferably within about 1 hour of each other.

In an embodiment of the invention, the kit may be administered threetimes per day. Preferably each daily dose is administered simultaneouslyi.e. sulindac and Compound A are taken together or formulated as asingle composition. In this embodiment, most preferably, it isformulated as a single composition, which is administered three timesdaily. Preferably each dose comprises 100 mg to 130 mg of sulindac. Eachdaily dose may also be administered sequentially i.e. at about the sametime, and preferably within about 1 hour of each other.

In an embodiment of the invention, the kit may be administered fourtimes per day. Preferably each daily dose is administered simultaneouslyi.e. sulindac and Compound A are taken together or formulated as asingle composition. In this embodiment, most preferably, it isformulated as a single composition, which is administered four timesdaily. Preferably each dose comprises 75 mg to 100 mg of sulindac. Eachdaily dose may also be administered sequentially i.e. at about the sametime, and preferably within about 1 hour of each other.

In an embodiment of the invention, the composition is administered atleast once a day. Preferably it is administered as a single daily dose.Preferably the single daily dose comprises of 200 mg to 400 mg ofsulindac, preferably 300 mg to 400 mg. Preferably it comprises 200 mg,250 mg, 300 mg, 350 mg or 400 mg.

Alternatively, the composition may be administered twice daily.Preferably each dose comprises 150 mg to 200 mg of sulindac, with atotal daily dosage of sulindac of 300 mg to 400 mg. Preferably itcomprises 150 mg or 200 mg. Most preferably, each daily dose comprises200 mg of sulindac, with a total daily dosage of sulindac of 400 mg.

Alternatively, the composition may be administered three daily.Preferably each dose comprises 100 mg to 130 mg of sulindac.

Alternatively, the composition may be administered four times daily.Preferably each dose comprises 75 mg to 100 mg of sulindac.

Preferably, the dosage regime is such that the total daily dose ofsulindac does not exceed 400 mg. Preferably the total daily dose ofCompound A does not exceed the maximum daily dose recommended by themanufacturer. In order to treat fragile x syndrome, the kits and/orcompositions are used in a chronic dosage regime i.e. chronic, long-termtreatment.

The present invention also relates to a kit or composition as describedherein for the manufacture of a medicament for use in the treatment offragile x syndrome. This embodiment of the invention may have any of thepreferred features described above.

The present invention also relates to a method of treating fragile xsyndrome comprising administering the patient with a kit or compositionas described herein. This embodiment of the invention may have any ofthe preferred features described above. The method of administration maybe according to any of the routes described above.

The present invention also relates to use of sulindac, or apharmaceutically acceptable salt thereof, for the manufacture of amedicament for the treatment of a patient with fragile x syndrome,wherein the patient has been administered with Compound A or apharmaceutically acceptable salt thereof. This embodiment of theinvention may have any of the preferred features described above.

The present invention also relates to use of Compound A, or apharmaceutically acceptable salt thereof, for the manufacture of amedicament for the treatment of a patient with fragile x syndrome,wherein the patient has been administered with sulindac or apharmaceutically acceptable salt thereof. This embodiment of theinvention may have any of the preferred features described above.

The present invention also relates to use of sulindac, or apharmaceutically acceptable salt thereof, and Compound A, or apharmaceutically acceptable salt thereof, for the manufacture of amedicament for the treatment of fragile x syndrome. This embodiment ofthe invention may have any of the preferred features described above.

For the avoidance of doubt, the present invention also embraces prodrugswhich react in vivo to give a compound of the present invention.

The following study illustrates the invention.

Study 1 Animals

Fmr1 knockout 2 (Fmr1 KO2) mice were generated by deletion of thepromoter and first exon of Fmr1 (Mientjes et al., 2006). The Fmr1 KO2 itis both, protein and mRNA null. In this study we used Fmr1 KO2 andwild-type (WT) littermates generated on a C57BL/6J background andrepeatedly backcrossed onto a C57BL/6J background for more than eightgenerations.

Animal Housing

The Fmr1 KO2 mice were housed in 4-5 per cage groups of the samegenotype in a temperature- (21±1° C.) and humidity-controlled room witha 12-hr light-dark cycle (lights on 7 a.m.-7 p.m.). Food and water wereavailable ad libitum. Mice were housed in commercial plastic cages, andexperiments were conducted in accordance with the requirements of the UKAnimals (Scientific Procedures) Act, 1986. Protocols were reviewed andapproved by the IEB, University of Chile Institute review board. Allexperiments were conducted with the FRAXA-DVI staff blinded to genotypeand drug treatment. Separate investigators prepared and coded the dosingsolutions, allocated the mice to the study treatment groups, dosed theanimals, and collected the behavioral data.

Treatment Groups

There were four treatment groups per compound/compound combination inthe study with 10 male mice used per treatment group (all at 8 weeks ofage): Group 1: Fmr1 KO2 mice treated with vehicle (Fmr1 KO2-V), Group 2:wild-type littermate mice treated with vehicle (WT-V), Group 3: Fmr1 KO2mice treated with compounds (Fmr1 KO-[name of drug(s)]) and Group 4:wild-type littermate mice treated with compounds (WT-[name of drug(s)]).

Compound Information

Sulindac was purchased from Sigma Aldrich. Synonym:(Z)-5-Fluoro-2-methyl-1-[p-(methylsulfinyl) benzylidene] indene-3-aceticacid

Metoprolol was purchased from Sigma Aldrich. Synonym: (±)-Metoprolol(+)-tartrate salt, (±) 1-(Isopropylamino)-3-[p-(β-methoxyethyl)phenoxy]-2-propanol (+)-tartrate salt, Lopressor

Dosing FIG. 1A, FIG. 1B, FIG. 1C and FIG. 1D:

Sulindac: 5 mg/kg by osmotic minipumps (ALZET Osmotic Pumps Cupertino,Calif., USA) implanted subcutaneously for 15 days delivery.

FIG. 2A, FIG. 2B, FIG. 2C and FIG. 2D:

Metoprolol: 10 mg/kg by osmotic minipumps implanted subcutaneously for15 days.

FIG. 3A, FIG. 3B, FIG. 3C and FIG. 3D:

Sulindac: 5 mg/kg by osmotic minipumps implanted subcutaneously for 15days. Ibudilast: 3 mg/kg by osmotic minipumps implanted subcutaneouslyfor 15 days. KO+Sul/Ibu: 5 mg/kg of sulindac and 3 mg/kg of ibudilast byosmotic minipumps implanted subcutaneously for 15 days.

FIG. 4A, FIG. 4B, FIG. 4C and FIG. 4D:

Sulindac: 5 mg/kg by osmotic minipumps implanted subcutaneously for 15days. Sertraline: 1 mg/kg by osmotic minipumps implanted subcutaneouslyfor 15 days. KO+Sul/Ser: 5 mg/kg of sulindac and 1 mg/kg of sertralineby osmotic minipumps implanted subcutaneously for 15 days.

FIG. 5A, FIG. 51B, FIG. 5C, FIGS. 5D and 5E:

Sulindac: 5 mg/kg by osmotic minipumps implanted subcutaneously for 15days. Quercetin: 1 mg/kg by osmotic minipumps implanted subcutaneouslyfor 15 days. KO+Sul/Quer: 5 mg/kg of sulindac and 100 mg/kg of quercetinby osmotic minipumps implanted subcutaneously for 15 days.

FIG. 6A, FIG. 6B, FIG. 6C and FIG. 6D:

Sulindac: 5 mg/kg by osmotic minipumps implanted subcutaneously for 15days. Cannabidiol: 5 mg/kg by osmotic minipumps implanted subcutaneouslyfor 15 days. KO+Sul/CBD: 5 mg/kg of sulindac and 5 mg/kg of cannabidiolby osmotic minipumps implanted subcutaneously for 15 days.

FIG. 7A, FIG. 7B, FIG. 7C and FIG. 7D:

Sulindac: 5 mg/kg by osmotic minipumps implanted subcutaneously for 15days. Minocycline: 30 mg/kg by osmotic minipumps implantedsubcutaneously for 15 days. KO+Sul/Min: 5 mg/kg of sulindac and 30 mg/kgof minocycline by osmotic minipumps implanted subcutaneously for 15days.

FIG. 8A, FIG. 8B, FIG. 8C, FIG. 8D and FIG. 8E:

Sulindac: 5 mg/kg by osmotic minipumps implanted subcutaneously for 15days. KO+S+T 5 mg/kg of sulindac and 47 mg/kg of topiramate by osmoticminipumps implanted subcutaneously for 15 days.

Behavioral Testing

For experiments, all mice were tested once in the same apparatus. Priorto testing, mice were placed in the apparatus for some minutes beforethe experiment. The apparatus was cleaned with moist and dry tissuesbefore testing each mouse. The aim was to create a low but constantbackground mouse odor for all experimental subjects. Testers were blindto the genotype and treatment during all testing and data analysis. Weassessed weight loss, fur loss, walking, eyes open, eye discharges andgeneral behavior. All signs indicated that all treatments were welltolerated by the Fmr1KO2 mice and WT littermates at all times.

Open Field

The open-field apparatus was used to test hyperactivity. The apparatuswas a gray PVC-enclosed arena 50×9×30 cm divided into a 10×10 cm grid.Mice were brought to the experimental room 5-20 min before testing. Amouse was placed into a corner square facing the corner and observed for3 min. The number of squares entered by the whole body (locomotoractivity) were counted. The movement of the mouse around the field wasrecorded with a video tracking device for 3 min (version NT4.0,Viewpoint).

Nesting

The test was performed in individual cages. Normal bedding covered thefloor to a depth of 0.5 cm. Each cage was supplied with a “Nestlet,” a 5cm square of pressed cotton batting (Ancare). Mice were placedindividually into the nesting cages 1 hr. before the dark phase, and theresults were assessed the next morning. Nest building was scored on a 5point scale.

Score 1: The Nestlet was largely untouched (>90% intact).

Score 2: The Nestlet was partially torn up (50-90% remaining intact).

Score 3: The Nestlet was mostly shredded but often there was noidentifiable nest site: <50% of the Nestlet

Score 4: An identifiable, but flat nest <90% of the Nestlet was torn up,the material was gathered into a flat nest with walls higher than themouse height curled up on its side) on less than 50% of itscircumference.

Score 5: A (near) perfect nest: >90% of the Nestlet was torn up, thenest was a crater, with walls higher than mouse body height on more than50% of its circumference.

Fear Conditioning

The dependent measure used in contextual fear conditioning was afreezing response following a pairing of an unconditioned stimulus (footshock), with a conditioned stimulus, a particular context. Freezing is aspecies-specific response to fear, which has been defined as “absence ofmovement except for respiration”. This may last for seconds to minutesdepending on the strength of the aversive stimulus, the number ofpresentations, and the degree of learning achieved by the subject.Testing involved placing the animal in a novel environment (darkchamber), providing an aversive stimulus (a 1-sec electric shock, 0.2mA, to the paws), and then removing it.

Social Interaction

In the three-chambered sociability task, a subject mouse was evaluatedfor its exploration of a novel social stimulus (novel mouse). Thethree-chambered social approach task monitors direct social approachbehaviors when a subject mouse is presented with the choice of spendingtime with either a novel mouse or an empty cup. Sociability is definedas the subject mouse spending more time in the chamber containing themouse than in the empty chamber. Preference for social novelty isdefined as spending more time in the chamber with the novel mouse. Theapparatus is a rectangular three-chamber box, where each chambermeasures 20 cm (length)×40.5 cm (width)×22 cm (height). Dividing wallsare made from clear perplex, with small openings (10 cm width×5 cmheight) that allow access into each chamber. The three chamber task waslit from below (10 lux). The mice were allowed to freely explore thethree-chamber apparatus over three 10 min trials. During the trial onewire cup was placed upside down in one of the side chambers and a novelmouse was placed under another wire cup in the other side chamber (novelmouse stimulus), leaving the middle chamber empty. The location of thenovel mouse across trials was counterbalanced to minimize any potentialconfound due to a preference for chamber location. The time spentexploring the novel mice was scored as exploration ratio.

Stereotypy

Rates of spontaneous stereotypy (head movements) were assessed using amodified automated photocell detection apparatus obtained from ColumbusInstruments (Columbus, Ohio). The testing protocol involved removingmice from their home cages and placing them singly in testing cages(22×25×28 cm) made of Plexiglas. The mice were left undisturbed for 2for habituation and recovery from the stress of handling prior to thebeginning of the testing. Food and water were provided. Each animalreceived a stereotypy score that represented the average stereotypyfrequency per hour.

Self-Grooming

Each mouse was placed individually into a standard mouse cage, (46 cmlength×23.5 cm wide×20 cm high), illuminated at ˜40 lux. After a 5-minhabituation period in the test cage, each mouse was scored in secondsfor cumulative time spent grooming all body regions.

Hyponeophagia

Mice are cautious when presented with a novel food in a novel place andthis is reflected in the latency to eat; the more anxious the animal,the longer the latency. To assist in test standardization (between groupand singly housed animals) the mice are put into new individualtemporary holding cages and allowed 20 min in the new cage in the testroom to adapt. Individual housing also prevents social transmission offood preferences. Full cream sweetened condensed milk diluted 50:50 withwater is used as the novel food. Mice are food restricted overnight:remove all food the evening before (also put down clean new bedding asthey're coprophagic) then give 1 g/mouse, which is approximately a thirdof what they would normally eat. If they are group housed make sure thatthe pieces are small so that all mice get equal shares. Test them thenext morning and replace their food as soon as testing is finished. Theapparatus is a white perspex base (30 cm²) to which is glued a food well1.2 cm in diameter, 0.9 cm high, filled with milk. To contain the mouseon the base and facilitate investigation of the milk, a translucentplastic jug (approximate volume 1.5 l, 15 cm diameter with a spoutprotruding a further 2 cm) is placed upside down with the spout forminga small alcove over the food well. This focuses the attention of themouse on to the well and the milk, so minimizing the effects oftreatments that might affect perception of, or orientation to, the foodsource. The mouse is placed facing away from the well and the jug isgently lowered into position, taking care not to trap the tail. Thelatency from being placed in the apparatus to start properly drinking istaken. Sniffs at the milk do not count, at least two seconds of lappingshould occur. Count any faecal boli and note any urination (note thatthese measures will be influenced by the time in the apparatus). Thecut-off time is 2 min. This time is probably optimal for anxiety levelsto decrease while still preserving a state of habituation to theapparatus. The test parameter is the (cumulative) latency to drink. Asin other tests where odor could play a significant role,non-experimental mice should be placed in the apparatus before testingstarts.

Statistical Analysis of Behavioral Data

Data were analyzed by two-way analysis of variance (ANOVA) followed bypost-test comparisons where appropriate using Tukey's MultipleComparison Test. Data are represented as the mean and standard error ofthe mean (SEM). Statistical analyses were performed in GraphPad Prism7.03.

Sulindac

The results can be seen in FIG. 1A, FIG. 1B, FIG. 1C and FIG. 1D.

A. Fifteen-day chronic treatment with sulindac normalizes hyperactivitydisplayed by the Fmr1 KO2 mice.

B. Fmr1 KO2 mice treated with sulindac showed normalization in nestingbehavior.

C. In the contextual memory test, freezing was reduced in Fmr1 KO2 micewhen compared to freezing of WT littermates. Treatment with Sulindacameliorates the Fmr1 KO deficit in learning and memory (KO not differentfrom WT, p=0.3968).

D. Fmr1 KO2 mice showed a significantly lower exploration index of thenovel mouse compared to WT mice (p<0.005), indicating impairedsociability. Sulindac partially improved such impairment in Fmr1 KO2mice.

Metoprolol

The results can be seen in FIG. 2A, FIG. 2B, FIG. 2C and FIG. 2D.

A. Chronic treatment with metoprolol normalized Fmr1 KO2 micehyperactivity as total distance travelled in the open field (p<0.005)

B. Nesting is partially rescued in the Fmr1 KO2 after metoprololtreatment.

C. The absence of FMRP protein impairs contextual fear conditioning;chronic treatment with metoprolol fails to improve the learning deficitsobserved in the Fmr1 KO2 mouse.

D. No significant difference was found in sociability in Fmr1 KO2 micetreated with metoprolol compared to drug treated WT mice (p<0.0001).

As seen in FIG. 1A-FIG. 1D, Chronic treatment with sulindacsignificantly improved the Fmr1 KO2 mouse phenotype, fully rescuing openfield and nesting behavior, while partially rescuing contextual fearconditioning and sociability. As can be seen from FIG. 2A-FIG. 2D,chronically administering metoprolol was able to normalize hyperactivityand partially rescue nesting behavior and sociability. This is evidencethat sulindac and metoprolol are useful in the therapy of fragile xsyndrome.

Sulindac and Ibudilast

As can be seen from FIG. 3A-FIG. 3D, the combination of sulindac andibudilast rescued sociability without affecting other behavioral tests.A synergistic effect is seen as, at the dosage amounts used, neithersulindac nor ibudilast alone rescues sociability. Open field, fearconditioning and nesting are rescued by ibudilast in combination withsulindac, showing no interference. This is evidence that the combinationof sulindac and ibudilast is useful in the treatment of FXS, and showssynergistic effects.

Sulindac and Sertraline

As can be seen from FIG. 4A-FIG. 4D, the combination of sulindac andsertraline rescued fear conditioning and sociability without affectingother behavioral tests. A synergistic effect is seen as, at the dosageamounts used, neither sulindac nor sertraline alone rescues sociabilityor fear conditioning. Open field and nesting are rescued by sertralinein combination with sulindac, showing no interference. This is evidencethat the combination of sulindac and sertraline is useful in thetreatment of FXS, and shows synergistic effects.

Sulindac and Quercetin

As can be seen from FIG. 5A-FIG. 5E, the combination of sulindac andquercetin rescued fear conditioning without affecting other behavioraltests. A synergistic effect is seen as, at the dosage amounts used,neither sulindac nor quercetin alone fully rescues fear conditioning.Nesting and open field are rescued by sulindac and quercetin incombination, showing no interference. The combination of sulindac andquercetin rescued sociability. This is evidence that the combination ofsulindac and quercetin is useful in the treatment of FXS, and showssynergistic effects.

Sulindac and Cannabidiol

As can be seen from FIG. 6A-FIG. 6D, the combination of sulindac andcannabidiol fully rescued open field, nesting and fear conditioning.Sociability was slightly improved by the combination of sulindac andcannabidiol. The two drugs do not interfere with each other. This isevidence that the combination of sulindac and cannabidiol is useful inthe treatment of FXS.

Sulindac and Minocycline

As can be seen from FIG. 7A-FIG. 7D, the combination of sulindac andminocycline was fully active, rescuing all behavioral tests. The twodrugs do not interfere with each other. This is evidence that thecombination of sulindac and minocycline is useful in the treatment ofFXS.

Sulindac and Topiramate

As can be seen from FIG. 8A-FIG. 8E, the combination of sulindac andtopiramate was fully active, rescuing all behavioral tests. The twodrugs do not interfere with each other. This is evidence that thecombination of sulindac and topiramate is useful in the treatment ofFXS.

1-29. (canceled)
 30. A method of treating fragile x syndrome bycombination therapy in a subject in need thereof comprisingadministering to the subject simultaneously, separately or sequentiallyan effective amount of the combination of: sulindac, or apharmaceutically acceptable salt thereof; and (ii) ibudilast or apharmaceutically acceptable salt thereof.
 31. The method of claim 30,wherein the subject exhibits signs of hyperactivity, social anxiety,memory loss, or disruptive behaviour.
 32. The method of claim 30,wherein the subject is human.
 33. The method of claim 30, whereinsulindac and ibudilast are administered simultaneously in a single doseonce per day.
 34. The method of claim 33, wherein the single dosecomprises 200 mg to 400 mg of sulindac.
 35. The method of claim 30,wherein sulindac and ibudilast are administered simultaneously in asingle dose twice per day.
 36. The method of claim 35, wherein thesingle dose comprises 150 mg to 200 mg of sulindac.
 37. The method ofclaim 30, wherein sulindac and ibudilast are administered orally. 38.The method of claim 30, wherein sulindac and ibudilast are administeredparenterally, transdermally, sublingually, rectally or by inhalation.39. The method of claim 30, wherein the subject is human; and sulindacand ibudilast are administered simultaneously in a single dose once perday.
 40. The method of claim 30, wherein the subject is human; andsulindac and ibudilast are administered simultaneously in a single dosetwice per day.